'Posterior (SMA-first) Approach' Versus 'Standard Approach' in Terms of Resection Margin and Long-Term Survival After Pancreaticoduodenectomy for Periampullary and Pancreatic Carcinoma: A Randomized Trial
In brief
SMA-first pancreaticoduodenectomy achieves similar 82% R0 resection rate as standard
In a randomized trial of 183 patients, the posterior SMA-first approach did not improve margin clearance, lymph-node yield, or long-term survival compared with the conventional technique, despite modestly higher intra-operative blood loss. Both groups had comparable recurrence-free (about 48 vs 44 months) and overall survival (about 53 vs 51 months), suggesting the newer approach offers no oncologic advantage.
- Journal
- Journal of surgical oncology (Q1)
- Published
- 3 September 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Hemant Ashok Jain, Gursagar Singh Sahota, Anand Narayan Singh, Rajni Yadav, Prasenjit Das, Nihar Ranjan Dash, et al.
- PMID
- 42693632
- DOI
- 10.1002/jso.70347
Why clinicians should know about it
- Picked for Surgical Oncology (top studies of the week, 6 September 2026): SMA‑first vs standard approach in pancreaticoduodenectomy RCT
- Picked for Surgery (paper of the day, 5 September 2026): Posterior (SMA‑first) vs standard approach RCT
Abstract
INTRODUCTION: SMA-first-approach in pancreaticooduodenectomy (PD) was found to be associated with better oncological outcomes as compared to the standard approach both in our pilot study and a few retrospective studies. Hence, we performed a randomized controlled trial to compare these two approaches in terms of resection margins, lymph node-retrieval, and long-term survival. METHODS: Between January 2014 to December 2018, all the consecutive patients undergoing PD for periampullary cancer at the Department of Gastrointestinal Surgery, AIIMS, New Delhi were assessed for randomization. Primary outcomes were R0 resection rate and number of lymph nodes retrieved. The secondary outcomes were operating time, blood loss, postoperative complications, recurrence free and overall survival. RESULTS: Of 299 patients assessed, 203 were randomized and 183 analyzed (20: excluded after randomization, 90: patients-SMA, 93: patients-classical). The median age of the study population was 56 (14-78) years, with predominantly male (138, 68%) and with periampullary tumors (89%). The demographic profile, preoperative clinical and laboratory parameters were comparable. The blood loss was significantly higher in SMA first group (675 vs 600 ml, p = 0.02), however the operating time and the need for blood transfusion were comparable in both groups. ISGPS Grade B/C pancreatojejunostomy leak (20 vs 24.7%, p = 0.68), post-pancreatectomy hemorrhage (8.8 vs 14%, p = 0.38), delayed gastric emptying (37.8 vs 40.9%, p = 0.67) and Clavien-Dindo grade ≥III complications(27.7 vs 31.2, p = 0.85) were similar in both the groups. The R0 resection rates (82.2 vs 78.5%, p = 0.53) and total lymphnodes retrieved (18 vs 17, p = 0.63) were similar between the two groups. Both groups were comparable in terms of median recurrence free (48 vs 44 months, p = 0.85) and overall survival (53 vs 51 months, p = 0.69). CONCLUSIONS: 'Posterior (SMA-first) approach' and 'Standard approach' for pancreatoduodenectomy for periampullary cancer yielded equivalent results in terms of R0 resection rate, number of lymph nodes retrieved, recurrence-free and overall-survival.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.